CAJ | 학술논문

病案资料是医疗行为过程中形成的真实、客观文字记录，是医疗纠纷诉讼及医疗鉴定的无可替代的书面证据。而当下医疗过程中仍存在病案质量缺陷及医疗制度不落实、病案资料保管不善、质控不严、责任心缺失等问题。本文通过9例典型案例分析，从不同侧面提示病案资料作为医疗诉讼的证据链存在不容忽视的较大缺陷，是造成医疗纠纷的重要原因。因此，提高医务人员法律意识与责任心、修炼基本功、加强病案资料管理，规范医疗行为，才能有效规避医疗纠纷的发生。
병안자료시의료행위과정중형성적진실、객관문자기록，시의료규분소송급의료감정적무가체대적서면증거。이당하의료과정중잉존재병안질량결함급의료제도불락실、병안자료보관불선、질공불엄、책임심결실등문제。본문통과9례전형안례분석，종불동측면제시병안자료작위의료소송적증거련존재불용홀시적교대결함，시조성의료규분적중요원인。인차，제고의무인원법률의식여책임심、수련기본공、가강병안자료관리，규범의료행위，재능유효규피의료규분적발생。
The medical records materials were factual and objective written records formed during medical treatment process, which were written evidence that could not be replaced in medical disputes litigation and medical identification. There are still many problems existing in current medical treatment process such as quality defects of medical records, implementation deficiency medical system, inappropriate storage of medical records materials, not strict quality control and lack of accountability and other issues. Through analysis on 9 cases of typical cases, this article indicated that as the evidence chain in the medical litigation, the larger defects that could not be ignored existing in them were the important cause of medical disputes. Therefore, we should enhance the legal awareness and responsibility of medical staff, practicing basic skills, strengthen the management of medical records materials and standardize the medical practices, so as to avoid the occurrence of medical disputes.